Reconsider the management of all coronary artery disease patients: Importance of the EUROPA trial

In patients at risk for cardiovascualr disease or with ischemic cardiomyopathy ACE inhibitors have been shown to reduce ischaemic events. Whether similar beneficial effects occur in the larger population of patients with coronary artery disease (CAD), but a low risk profile and without left ventricular dysfunction and/or heart failure, is unknown. The anti-atherosclerotic effects of ACE inhibition are due to a dual mode of action, inhibition of angiotensin II production and enhancing bradykinin formation. As a result, ACE inhibitors reduce smooth muscle cell proliferation, improve vascular endothelial function, decrease palque rupture, enhance fibronlysis, modulate cytokine activation and lead to anti-inflammatory and anti-oxidative effects. ACE inhibitors are also anti-hypertensive agents that reduce left ventricular hypertrophy and myocardial oxygen demand. It is therefore to be expected that, together, these multiple effects may lead to marked secondary prevention in all patients with CAD, irrespective of cardiac function or further risk profile. The EUROPA study aims at investigating this hypothesis. The primary objective of EUROPA is a reduction in cardiovascular death, non-fatal myocardial infarction and/or successful resuscitation during an approximate 4-year randomized, double-blind study in over 12000 patients, comparing the ACE inhibitor perindopril with placebo. It aims to prove that ACE inhibition with perindopril will lead to secondary prevention of cardiovascular events in all patients with CAD.